02100171 (2) CITY OF CUPEWrINO
BUILDING DIVISION PERMIT X ,QNTRACTQR INFORMATIQN`s V..
BDI E VD KYUB KHAN PERMI'rNG2100171
Wg'�11IT8 E:KHAIQ APPLICA pOSpQ4T.2OOZ
ONE: SANITARY NO. CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
as ad LICENSIiDCONTRACTOR'S
nsedunderpDECLARATION ]
Z C 1 hereby off run that I am licensed under ad Prof ro of Chapter d(commencing ADD 725 S Q. IF1 Q�Description
�r�I�
w withllfor, ]rdeff Division Jnf NC Buv nil Pmfcssinns Cndc,and my license is N
FOL in lullfomc Jcffcct 74
2I�/,
OZ— License Lica /—
Uam Cant c
£ ARCHITECTSDT.cL RATION MAR 3 12003
OI understand my plans shall be used as public records
U
LL Licensed Professional BUILDING
OWNI3RBUILDER DIiCLARATION
u�<p I hereby affirm that 1 am exempt from the Contractor's License Law for the $105000
HS 00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
s�$ which re41111.a permit to construe,alter.improve.demolish,or"air any structure
F Z>' poor to its issuance,also roddires the applicant for such permit o file a signed statement nn
qq < that he is lice used pursuant us the previsions of the Connector's License Law(Chapter 9 3945200deR� erg Valuation
(commend ag with Section 70(m)(it Division 3 of the Busi ness and Profusions Code)or
— that he is exempt dumfound and the basis for Ne alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicanto a civil penalty of LUAPNN anC Occu Type
not tome than five hundred dollars/55001 10 2 — PIERS Occupancy yp
❑ I.uow.,of the property,or my employees with wag.is Nei,ax le compensation,
will do the work,and the structure is not intended Or Offered for sale(Sec.7044,Business
and Professions Code:The Cumbeedn's License Law does not apply N an owner of 104 - REBAR Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If. 105 — ANCHOR BOLTS
however.the building of improvement is sold within one,year of completion,the owner. lO6 — SEWER & WATER
builder will have the burden of proving that he did not build or improve for puq uee of
arle')' 202 - UNDERFLOOR PLUMBING
❑ 1,as owner of Ne property,am exclusively conducting with licensed contractors m 2 03 - UNDERFLOOR MECHANICAL
construe the project(See.70,14,Business and Professions Cotler)The Contractor's Li.
cense Law does net pply to an owner of property who holds or improves therson,and 204 - UNDERFLOOR FRAME
who contracts for such projects with a mnuactsubd licensed pursuant to me Combactois 209 — UNDERFLOOR INSULATION
License Law.
❑I am exempt under Sec. ,B&P C for reason 301 - ROUGH PLUMBING
caner Dau 302 - TUB & OR SHOWER
WOR K ER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby affirm under penalty of perjury 000 of the following declarations: ,304 — ROUGH ELECTRICAL
❑ I have and will maintain a Coffers,of ConsenGo self-insum for Worker's Counter.
union,as provided for by Section 37(1 of the Labor Code.for the performance of the 3 05 — FRAME
work for which this permit is issued. 306 — HOLDOWNS
❑L have and will maintain Workers Compensation Inmranec,as required by Section 3 07 - INSULATION
37M of the Labor Cale,for Neper(or man.of the woo,for which this permit is issued.
My Wnrker'�onry tion l ounce carrier andPulify number am: 308 — SHEETROCK
ca err polik' L9ar 309 - EXTERIOR LATH
CER FIC
COMPENSATION IINSURANCE
ON FROM ORKERS' 310 — INTERIOR LATH
Ons section need not W completed ifine fr.i.is forms hundred dollars H I00) 311 - SCRATCH COAT
or less.) 313 - ROOF NAIL
1 codify that in the terfornorce Of the work fn,which this permit is issued,I shall not 5 01 - FINAL ELECTRICAL ENERGY
employ any peraun in any manner so.to become subject to the Workers'Compensation
Laws of Califomia.Date 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICAW.If,after making this Ccrificatc of Exemption,you should 503 - FINAL MECHANICAL ENERGY
Mcome subject to the Worker's Compensation previsions of the Labor Code,you must 504 - FINAL BUILDING ENERGY
0o forthwith comply with such provisions or this termitshagMdeemed revoked. 505 - FINAL ELECTRICAL
Z CONSTRUCTION LENDING AGENCY
[-� Ihemhy ME.that there is a construction lending agency for the preformanecof 506 — GAS TEST
the work for which this Permit is issued(Sec.307.Civ.C.) 507 - FINAL PLUMBING
f41 Q Lender's Name
z Leader'sAJdress 508 - FINAL MECHANICAL
U O 1 codify Nat I have read this application and watt that the sinew information is 509 - FINAL GRADE
f+ confect l agree to comply with all city and county Ordinances and sate laws relating to 5 FINAL PLANNING
building construction,and hereby saturation at
mimsenivus of Nis city to enar uton the
W� above-memined property far nscsonnpurposes.
14 FIN PUBLIC WORKS(Wc)agree to saw,indemnify mal
keep harmless The City of Cupertino against
Cat
liabilities,judgments,ofh,grand ng
es tis From
may in anyway acerae against said City
U z A APPLICANT
Of the UNDERSTANDS
this permit.
r-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCE R GULATIO $� I
C.Iry Re-roofs
tgnamrc of plicanVCnmracmr Dec
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nc applicant nr future building Occupant store or handle hazardous memrial
as defined by the Cupedino Municipal Code.Chapter 9.12.and the Health and Safety
We, 0Yrazss3z(a)! All roofs shall be inspected prior to any roofing material being installed.
❑Yu x]Nu
Will the applicant or future building os'cupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminandtassas defined by the Bay Area Air Quality Management all new materials for inspection,
❑Yes @yNu
I have real the hmardeds materials mquimmens under Chapter 6.95 of the Caliler-
nis IIcaW&Safety Code.Nations 25505,25533 and 25534.1 undersand that if the building
does not currently have a tenant.Nat it is my responsibility m notify the Occupied of the
bi whichred1 etpnarbeissuariofa4dB1.¢ef0.cnpan . Signature of Applicant Date
�12
Ownerorised agent Dat All roof coverings to be Class"B" or better
o